Provider Demographics
NPI:1063404572
Name:KISTNER, ROBERT L JR (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:KISTNER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 50970
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85076-0970
Mailing Address - Country:US
Mailing Address - Phone:480-706-6151
Mailing Address - Fax:480-706-8908
Practice Address - Street 1:2755 SILVER CREEK RD STE 111
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8343
Practice Address - Country:US
Practice Address - Phone:928-704-7163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ20804174400000X
OH35056109208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0491638Medicaid
AZ130170Medicaid
AZ130170Medicaid